ACR Technical Standard for Medical Nuclear

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The American College of Radiology, with more than 30,000 members, is the principal organization of radiologists, radiation oncologists, and clinical
medical physicists in the United States. The College is a nonprofit professional society whose primary purposes are to advance the science of radiology,
improve radiologic services to the patient, study the socioeconomic aspects of the practice of radiology, and encourage continuing education for
radiologists, radiation oncologists, medical physicists, and persons practicing in allied professional fields.
The American College of Radiology will periodically define new practice parameters and technical standards for radiologic practice to help advance the
science of radiology and to improve the quality of service to patients throughout the United States. Existing practice parameters and technical standards
will be reviewed for revision or renewal, as appropriate, on their fifth anniversary or sooner, if indicated.
Each practice parameter and technical standard, representing a policy statement by the College, has undergone a thorough consensus process in which it has
been subjected to extensive review and approval. The practice parameters and technical standards recognize that the safe and effective use of diagnostic
and therapeutic radiology requires specific training, skills, and techniques, as described in each document. Reproduction or modification of the published
practice parameter and technical standard by those entities not providing these services is not authorized.
Revised 2013 (Resolution 42)*
ACR–AAPM TECHNICAL STANDARD FOR MEDICAL NUCLEAR PHYSICS
PERFORMANCE MONITORING OF GAMMA CAMERAS
PREAMBLE
This document is an educational tool designed to assist practitioners in providing appropriate radiologic care for
patients. Practice Parameters and Technical Standards are not inflexible rules or requirements of practice and are
not intended, nor should they be used, to establish a legal standard of care1. For these reasons and those set forth
below, the American College of Radiology and our collaborating medical specialty societies caution against the
use of these documents in litigation in which the clinical decisions of a practitioner are called into question.
The ultimate judgment regarding the propriety of any specific procedure or course of action must be made by the
practitioner in light of all the circumstances presented. Thus, an approach that differs from the guidance in this
document, standing alone, does not necessarily imply that the approach was below the standard of care. To the
contrary, a conscientious practitioner may responsibly adopt a course of action different from that set forth in this
document when, in the reasonable judgment of the practitioner, such course of action is indicated by the condition
of the patient, limitations of available resources, or advances in knowledge or technology subsequent to
publication of this document. However, a practitioner who employs an approach substantially different from the
guidance in this document is advised to document in the patient record information sufficient to explain the
approach taken.
The practice of medicine involves not only the science, but also the art of dealing with the prevention, diagnosis,
alleviation, and treatment of disease. The variety and complexity of human conditions make it impossible to
always reach the most appropriate diagnosis or to predict with certainty a particular response to treatment.
Therefore, it should be recognized that adherence to the guidance in this document will not assure an accurate
diagnosis or a successful outcome. All that should be expected is that the practitioner will follow a reasonable
course of action based on current knowledge, available resources, and the needs of the patient to deliver effective
and safe medical care. The sole purpose of this document is to assist practitioners in achieving this objective.
1 Iowa Medical Society and Iowa Society of Anesthesiologists v. Iowa Board of Nursing, ___ N.W.2d ___ (Iowa 2013) Iowa Supreme Court refuses to find
that the ACR Technical Standard for Management of the Use of Radiation in Fluoroscopic Procedures (Revised 2008) sets a national standard for who may
perform fluoroscopic procedures in light of the standard’s stated purpose that ACR standards are educational tools and not intended to establish a legal
standard of care. See also, Stanley v. McCarver, 63 P.3d 1076 (Ariz. App. 2003) where in a concurring opinion the Court stated that “published standards or
guidelines of specialty medical organizations are useful in determining the duty owed or the standard of care applicable in a given situation” even though
ACR standards themselves do not establish the standard of care.
Nuclear Medicine Physics
TECHNICAL STANDARD
2013 Resolution No. 42
I.
INTRODUCTION
This technical standard was revised collaboratively by the American College of Radiology (ACR) and the
American Association of Physicists in Medicine (AAPM).
All nuclear medicine imaging equipment must be tested upon installation and monitored at least annually by a
Qualified Medical Physicist to ensure that it is functioning within manufacturer specifications and accepted
performance standards. Additional or more frequent performance monitoring may be necessary in certain
situations (e.g., after major equipment maintenance). Although it is not possible to consider all variations of
equipment performance to be monitored, adherence to this technical standard will maximize image quality and
help to ensure the accuracy of numerical results in clinical procedures. Key points to consider are performance
characteristics to be monitored, estimated patient radiation dose, qualifications of personnel, and follow-up
procedures.
The goal is to produce the highest quality diagnostic image consistent with the clinical use of the equipment and
the information requirement of the examination and to establish performance standards for the imaging
instruments.
II.
QUALIFICATIONS AND RESPONSIBILITIES OF A QUALIFIED MEDICAL PHYSICIST
A Qualified Medical Physicist is an individual who is competent to practice independently in one or more of the
subfields in medical physics. The American College of Radiology (ACR) considers certification, continuing
education and experience in the appropriate subfield(s) to demonstrate that an individual is competent to practice
one or more of the subfields in medical physics, and to be a Qualified Medical Physicist. The ACR strongly
recommends that the individual be certified in the appropriate subfield(s) by the American Board of Radiology
(ABR), the Canadian College of Physics in Medicine, or the American Board of Medical Physics (ABMP).
A Qualified Medical Physicist should meet the ACR Practice Parameter for Continuing Medical Education
(CME). (ACR Resolution 17, adopted in 1996 – revised 2012, Resolution 42)
The appropriate subfield of medical physics for this technical standard is Nuclear Medical Physics. (Previous
medical physics certification categories, including Radiological Physics and Medical Nuclear Physics, are also
acceptable.)
Certification in Nuclear Medicine Physics and Instrumentation by the American Board of Science in Nuclear
Medicine (ABSNM) is also acceptable.
The Qualified Medical Physicist must be familiar with the principles of radiation protection; the guidelines of the
National Council on Radiation Protection and Measurements (NCRP); laws and regulations governing the use of
the equipment being tested; the function, clinical uses, and performance specifications of the imaging equipment;
and calibration processes and limitations of the instruments and techniques used for testing performance.
The Qualified Medical Physicist may be assisted by properly trained individuals in obtaining data for performance
monitoring. These individuals must be approved by the Qualified Medical Physicist in the techniques of
performing tests, the function and limitations of the imaging equipment and test instruments, the reasons for the
tests, and the importance of the test results. The Qualified Medical Physicist is responsible for, and must review,
interpret, and approve all data as well as provide a signed report of the conclusions.
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TECHNICAL STANDARD
III.
PERFORMANCE CHARACTERISTICS TO BE MONITORED
A. Performance Evaluation
The following characteristics should be evaluated at least annually [1-11]:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Intrinsic uniformity
System uniformity with all commonly used collimators
Intrinsic or system spatial resolution/linearity
System sensitivity
a. Count rate per unit activity
b. Interdetector variability
Energy resolution
Count rate performance
Formatter/video display
a. Uniformity
b. Spatial resolution
Overall system performance for single photon emission computed tomography (SPECT)
a. Uniformity
b. Contrast
c. Spatial resolution
System interlocks
B. Quality Control Program
A continuous quality control (QC) program must be established for the nuclear medicine imaging equipment with
the assistance of a Qualified Medical Physicist as outlined in the ACR–SNM Technical Standard for Diagnostic
Procedures Using Radiopharmaceuticals [12,13]. An on-site technologist should be identified to be responsible
for conducting routine QC.
The results of the QC program must be monitored annually by the Qualified Medical Physicist. If measured
values of QC parameters fall outside the control limits, the physicist should initiate appropriate investigative or
corrective actions. A Qualified Medical Physicist should be available to assist in prescribing corrective actions for
unresolved problems.
C. Acceptance Testing
Initial performance testing of imaging equipment must be performed upon installation and should be completed
before clinical use. This testing should be more comprehensive than periodic performance testing and should be
consistent with current acceptance testing practices. Electrical safety of the equipment must also be tested by
appropriate personnel prior to its initial clinical use.
D. Written Survey Reports and Follow-Up Procedures
The Qualified Medical Physicist must report the findings to the physician(s), to the responsible professional(s) in
charge of obtaining or providing necessary service to the equipment, and, in the case of the consulting Qualified
Medical Physicist(s), to the representative of the hiring party. If appropriate, the Qualified Medical Physicist
should initiate the required service. Action should be taken immediately by direct verbal communication if there
is imminent danger to patients or staff using the equipment due to unsafe conditions. Written survey reports must
be provided in a timely manner consistent with the importance of any adverse findings. The Qualified Medical
Physicist should confirm that the unit is performing in a safe and acceptable fashion as soon as possible after the
required service is performed.
TECHNICAL STANDARD
Nuclear Medicine Physics / 3
IV.
RADIATION SAFETY IN IMAGING
Radiologists, medical physicists, registered radiologist assistants, radiologic technologists, and all supervising
physicians have a responsibility for safety in the workplace by keeping radiation exposure to staff, and to society
as a whole, “as low as reasonably achievable” (ALARA) and to assure that radiation doses to individual patients
are appropriate, taking into account the possible risk from radiation exposure and the diagnostic image quality
necessary to achieve the clinical objective. All personnel that work with ionizing radiation must understand the
key principles of occupational and public radiation protection (justification, optimization of protection and
application of dose limits) and the principles of proper management of radiation dose to patients (justification,
optimization and the use of dose reference levels)
http://www-pub.iaea.org/MTCD/Publications/PDF/Pub1578_web-57265295.pdf.
Facilities and their responsible staff should consult with the radiation safety officer to ensure that there are
policies and procedures for the safe handling and administration of radiopharmaceuticals and that they are
adhered to in accordance with ALARA. These policies and procedures must comply with all applicable radiation
safety regulations and conditions of licensure imposed by the Nuclear Regulatory Commission (NRC) and by
state and/or other regulatory agencies. Quantities of radiopharmaceuticals should be tailored to the individual
patient by prescription or protocol
Nationally developed guidelines, such as the ACR’s Appropriateness Criteria®, should be used to help choose the
most appropriate imaging procedures to prevent unwarranted radiation exposure.
Additional information regarding patient radiation safety in imaging is available at the Image Gently® for
children (www.imagegently.org) and Image Wisely® for adults (www.imagewisely.org) websites. These
advocacy and awareness campaigns provide free educational materials for all stakeholders involved in imaging
(patients, technologists, referring providers, medical physicists, and radiologists).
Radiation exposures or other dose indices should be measured and patient radiation dose estimated for
representative examinations and types of patients by a Qualified Medical Physicist in accordance with the
applicable ACR technical standards. Regular auditing of patient dose indices should be performed by comparing
the facility’s dose information with national benchmarks, such as the ACR Dose Index Registry, the NCRP
Report No. 172, Reference Levels and Achievable Doses in Medical and Dental Imaging: Recommendations for
the United States or the Conference of Radiation Control Program Director’s National Evaluation of X-ray
Trends. (ACR Resolution 17 adopted in 2006 – revised in 2009, 2013, Resolution 52).
A table of organ dose estimates should be prepared for all procedures that involve administration of
radiopharmaceuticals to patients. The table should specify the radiopharmaceutical dosage schedule used at the
facility. All organs that receive significant doses should be included. Separate values for standard patients of
different sizes should be tabulated where applicable. The table should be reviewed at least annually and updated
when any of the following occur: 1) the addition of new procedures and/or radiopharmaceuticals, 2) a change in
radiopharmaceutical dosage schedules, 3) a change in the route of administration, and 4) the availability of more
accurate dosimetry data [13,15-18]. For facilities performing pediatric imaging, the radiopharmaceutical dosage
should be adjusted to be appropriate to the size of the patient. It is recommended that the dosages closely follow
the activities as outlined in the North American Consensus Guidelines for Administered Radiopharmaceutical
Activities in Children and Adolescents [19].
ACKNOWLEDGEMENTS
This technical standard was revised according to the process described under the heading The Process for
Developing ACR Practice Guidelines and Technical Standards on the ACR website
(http://www.acr.org/guidelines) by the Guidelines and Standards Committee of the ACR Commission on Medical
Physics in collaboration with the AAPM.
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TECHNICAL STANDARD
Collaborative Committee – members represent their societies in the initial and final revision of this guideline
ACR
Bruce E. Hasselquist, PhD, Chair
Michelle L. Kritzman, MS
Robert A. Pooley, PhD
AAPM
Jerry D. Allison, PhD, FACR, FAAPM
Kishor M. Patel, PhD
Guy H. Simmons, PhD, FAAPM
Committee on Practice Parameters and Technical Standards – Medical Physics
(ACR Committee responsible for sponsoring the draft through the process)
Tariq A. Mian, PhD, FACR, FAAPM, Chair
Maxwell R. Amurao, PhD, MBA
Ishtiaq H. Bercha, MSc
Chee-Wai Cheng, PhD, FAAPM
Laurence E. Court, PhD
Nicholas J. Hangiandreou, PhD
Bruce E. Hasselquist, PhD
Ralph P. Lieto, MS, FACR, FAAPM
Jeffrey P. Limmer, MSc
Doug Pfeiffer, MS
Thomas G. Ruckdeschel, MS
Christopher J. Watchman, PhD
Gerald A. White, Jr., MS, FACR, FAAPM
John W. Winston, Jr., MS
Richard A. Geise, PhD, FACR, FAAPM, Chair, Medical Physics Commission
Debra L. Monticciolo, MD, FACR, Chair, Quality and Safety Commission
Julie K. Timins, MD, FACR, Chair, Committee on Guidelines
Comments Reconciliation Committee
Loralie D. Ma, MD, PhD, FACR, Chair
Tariq A. Mian, PhD, FACR, FAAPM, Co-Chair
Jerry D. Allison, PhD, FACR, FAAPM
Kimberly E. Applegate, MD, MS, FACR
Howard B. Fleishon, MD, MMM, FACR
Richard A. Geise, PhD, FACR, FAAPM
Bruce E. Hasselquist, PhD
Michelle L. Kritzman, MS
Debra L. Monticciolo, MD, FACR
Kishor M. Patel, PhD
Robert A. Pooley, PhD
Guy H. Simmons, PhD, FAAPM
Julie K. Timins, MD, FACR
Charles A. Wissuchek, MS
REFERENCES
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2003. Report 86.
2. Forstrom LA, Dunn WL, O'Connor MK, Decklever TD, Hardyman TJ, Howarth DM. Technical pitfalls in
image acquisition, processing, and display. Semin Nucl Med 1996;26:278-294.
3. Garcia EV, Faber TL. New trends in camera and software technology in nuclear cardiology. Cardiol Clin
2009;27:227-236, Table of Contents.
TECHNICAL STANDARD
Nuclear Medicine Physics / 5
4. Graham LS, Fahey FH, Madsen MT, van Aswegen A, Yester MV. Quantitation of SPECT performance:
Report of Task Group 4, Nuclear Medicine Committee. Med Phys 1995;22:401-409.
5. Henkin R ed. Nuclear Principles and Practices. Vol I and II. St. Louis, Mo: Mosby-Yearbook; 1996.
6. Hines H, Kayayan R, Colsher J, et al. National Electrical Manufacturers Association recommendations for
implementing SPECT instrumentation quality control. J Nucl Med 2000;41:383-389.
7. O'Connor MK. Instrument- and computer-related problems and artifacts in nuclear medicine. Semin Nucl Med
1996;26:256-277.
8. International Atomic Energy Agency. IAEA Quality Control Atlas for Scintillation Camera Systems.
http://www-pub.iaea.org/MTCD/publications/ PDF/Pub1141_ web.pdf. Accessed January 30, 2012.
9. Sandler M ed. Diagnostic Nuclear Medicine. 4th ed. Baltimore, Md: Lippincott, Williams and Wilkins; 2003.
10. Performance Measurements of Gamma Cameras. District of Columbia, DC: National Electrical
Manufacturers Association; 2007. Standards Publication NU 1-2007.
11. Quality Assurance for Radioactivity Measurement in Nuclear Medicine. Vienna, Austria: International
Atomic Energy Agency; 2006. Technical Reports Series No. 454.
12. ACR-SNM
technical
standard
for
diagnostic
procedures
using
radiopharmaceuticals.
http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines/nuc_med/radiopharmaceuticals.
aspx.Accessed January 24, 2012.
13. Society of Nuclear Medicine procedure guideline for general imaging 6.0. The Society of Nuclear Medicine
Procedure Guidelines Manual. Reston, Va: The Society of Nuclear Medicine; 2010.
14. Consolidated Guidance About Medical Use Licenses. District of Columbia, DC: Nuclear Regulatory
Commission. Final Report NUREG-1556, Volume 9; Rev 2, 2008.
15. Medical Internal Radiation Dose (MIRD) Reports. Reston, Va: Society of Nuclear Medicine.
16. Radiation Dose Estimated for Radiopharmaceuticals. District of Columbia, DC: Nuclear Regulatory
Commission. NUREG/CR 6345; 1996.
17. ICRP. Radiation Dose to Patients from Radiopharmaceuticals (Addendum to ICRP Publication 53). ICRP
Publication 80. Ann. ICRP 1998; 28 (3).
18. Oak Ridge Institute for Science and Education. Dose Estimates and Other Compendia.
http://orise.orau.gov/reacts/resources/dose-estimates.aspx. Accessed April 19, 2012.
19. Gelfand MJ, Parisi MT, Treves ST. Pediatric radiopharmaceutical administered doses: 2010 North American
consensus guidelines. J Nucl Med 2011;52:318-322.
*Practice parameters and technical standards are published annually with an effective date of October 1in the year
in which amended, revised, or approved by the ACR Council. For practice parameters and technical standards
published before 1999, the effective date was January 1 following the year in which the practice parameter or
technical standard was amended, revised, or approved by the ACR Council.
Development Chronology for this Technical Standard
1998 (Resolution 16)
Revised 2003 (Resolution 14)
Amended 2006 (Resolution16g, 17)
Revised 2008 (Resolution 5)
Revised 2013 (Resolution 42)
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TECHNICAL STANDARD
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